Host Report Form

This form is utilized for hosts who want to file a status report, complaint regarding their current student.

If this is an emergency, please contact your MHN representative immediately along with the appropriate help from emergency providers such as healthcare providers or law enforcement.

Please be detailed with the description of the update/ problem and answer ALL the questions below.

Host Name

Host Email Address

Student Name

Host Phone Number

How do you like your experience so far?

How often does the student talk to you?

Describe the reason for this report

What is the history/ timeline of this problem?

What actions and steps did you take to resolve this?

What was the result?

What would you further recommend to do?

Additional notes

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